Failure to Obtain Orders and Provide Wound Care for Pressure Ulcers
Penalty
Summary
The facility failed to obtain physician orders and provide wound care for a resident with multiple pressure ulcers. The resident was admitted with several wounds, including a stage one sacrum pressure ulcer, a right ankle deep tissue injury, and a left ankle stage three pressure ulcer. Additionally, two blisters on the plantar surfaces of the feet were identified as acquired in the facility. Review of the resident's medical record, medication administration records, and treatment administration records revealed that there were no physician orders or wound care provided for the sacrum, right ankle, or left ankle wounds for three consecutive days following admission. Interview with the wound nurse confirmed that wound care orders or treatments were not in place for these pressure wounds during the specified period. The facility's skin assessment policy required necessary care to prevent and treat pressure injuries, but this was not followed for the resident in question. The deficiency was identified during a complaint investigation and affected one resident with severe cognitive impairment and multiple mobility-related diagnoses.